Science topic

Pain Medicine - Science topic

Pain management or algiatry is a branch of medicine employing an interdisciplinary approach for easing the suffering and improving the quality of life of those living with pain.
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The Paolo Procacci Foundation, a foundation whose aim is to increase research and developments in Pain Medicine, is trying to develop new knowledges on inflammatory pain.
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I am interested in being part of the Advisory Board, my email: mpcalimag@ust.edu.ph
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I would like to know about correlation between that syndrome ad psychosomatic disorder.
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i am currently treating a GBS patient in the hospital. i am a neurologist with fellowship training in multiple sclerosis/neuroimmunology. psychosomatic disorder can present as GBS initially, but it can easily be differentiated from GBS, based on the history, exam, and ancillary testing. thanks, mustafa.
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Does anyone has real practical experience with the management of interstitial cystitis (IC)/ Bladder pain syndrome (BPS)? Is there an effective practical role for intravesical Botulinum Toxin (Botox)?
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I have used the agent in selected cases of BPS, usually where urinary frequency is also present and contributing to the pain. The response in my patients has been inconsistent. The benefit, when seen, is transient. Would certainly consider it in patients that have failed conventional therapy.
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when a patient complain osteoarthritis hip and knee ipsilateral which joint we start with hip or knee ?
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If we assume that the stage of damage is the same for both joints, then we have to discuss the schedule with the patient and take into consideration his/her complaints. I would do first the more painful joint. On the other hand, we have to take into consideration  the possibility of referred pain from the hip that intensifies the knee complaints. If this is the case, then hip first and knee later. However, some surgeons make an association with the building or repair of an old house. It is always started  from the foundation or basement. So I think both variants are possible, and the surgeon (and patient !) should decide individually from case to case.
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Is it necessary to take a lower limit as inclusion criteria for the ODQ? The design from our low back pain study is planned as randomized, sham treatment controlled trial. I am concerned about  getting a to small difference for the stats, if we don´t choose a lower limit.... Especially the between group difference...
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We published a paper in which we show an absolute ODI-value corresponding to patient acceptabel symptomen state (PASS) for the official ODI v.2.1a. An ODI <=22 equals PASS and seems corresponding to 'normal', healthy populations as well. I suggest to use ODI <=22 as a lower limit. Furthermore, it is known that a minimal clinical important difference is at least 10 points or 30% of the baseline value (Ostelo et al. 2008) and literature shows that an ODI >= 41 corresponds to longstanding chronicLBP. Hopefully, this information is of use.
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Hello,
  I am a 57 year old female who is morbidly obese and have suffered three strokes on the right side. I suffer from chronic pain and numbness. Not only on my right side but my lower back as well. Are there any medications for chronic pain that work that are not narcotics? I would appreciate any information you could provide.
Thank you,
Kathi J Peacock
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Every day-  did i say every day !  I meant 2x a day... LOL. It's the most common thing I see .....
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Dear all,
I have been searching the literature on the effective analgesic method during the reduction of simple shoulder and elbow dislocation, such as the use of intra-articular lidocaine and conscious sedation.
The literature is vast with comparative studies on intra-articular lidocaine and conscious sedation in the reduction of simple shoulder dislocations, however, I couldn’t find any comparative studies on simple elbow dislocations.
Provided that the elbow is the second most common dislocated joint in the body, Is there any scientific reason for the lack of studies on the elbow?
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I agree with Sergey but due to many issues general anesthesia isn't possible.  With the elbow a small amount of sedation with a joint infiltration of local works great.  The shoulder if done correctly also is good with a sedation to relax the musculature.
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Treatment of osteoarthritis hip is mainly surgical.Attempts to look at treatment options and traditional medication has not been well cited or published.
Do outline treatment options seeked by your patients in dealing with hip osteoarthritic pain and its success rate
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Do you mean "osteoartritis" (inflamation of the joint) or "osteoarthrosis" (degeneration of the joint)? There is a big difference, as far as conseravtive or surgical treatment is also concerned. 
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I had two patients with anal pain, probably proctalgia or anodynie with reporting of a burning or painfull sensation in the foot, mostly the sole.
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This is an interesting question. Maybe it is easier to answer with more information, e.g. is the anodynie a burning sensation too, or is it a different quality of pain? If both sensations are of burning quality, I would expect a neuropathy as the cause of painful sensation. Is the sensation chronic or does it only occur transiently in certain situations? Did the patients have other diseases, e.g. diabetic polyneuropathy? Did they take medication that might have caused this sensation as a side effect?
Based on the dermatome of the sole of the foot, one would expect L4 or S1, the anal region, on the other hand, is S3 to S5. You could be right that the proximity of the sacral nerves is responsible for this. Alternatively, you may consider the proximity of the genito-anal region and the foot in the somatosensory cortex (refer to map of neocortex).
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Do you  know of studies about the efficacy of intra articular injection of autologous fat in knee joint   osteoarthritis helping in pain relief or ligament regeneration ?
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Dear Khaled,
It is a pity that the full text is in German
Herold C, Fleischer O, Allert S. Autologous fat injection for treatment of carpometacarpal joint osteoarthritis of the thumb a promising alternative. Handchir Mikrochir Plast Chir 2014 Apr;46(2):108-12.
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The published research on Botox for Migraines generally suggests that it only works for Chronic and not Episodic Migraines.
However this is not my experience, and it does not fit with the history of how the effect was first a serendipitous discovery in people who were having Botox for their wrinkles!
I would suggest that the failure of Botox in treatine Episodic Migraines is a failure of the PREEMPT Protocol devised by Allergan. Because they were scared that injecting the corrugator muscles would cause a high incidence of lid ptosis so the existing protocol actively avoids injecting them, even though it suggests it does.
It is interesting that Silberstein/Allergan are now teaching people how to inject into the corrugators directly, though this is not yet published. Indeed one neurologist in the UK, who was shown the 'new' technique, was told that perhaps she shouldn't use it because it wasn't yet published
I use a much higher dose in the corrugators (see the articles in my project) and find it very effective in both chronic and episodic migraines
What have other people found?
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Pete Batcheller has written on Clusterheadache.com that "Regarding the optimum maintenance dose of vitamin D3... The best information available indicates the average sustained 25(OH)D response to a dose of 5,000 IU/day is 60 ng/mL while a maintenance dose of 10,000 IU/day results in a sustained average 25(OH)D response of 80 to 85 ng/mL."
I am unclear where these assertions come from, along with the variation in individual responses to the doses. 
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Referred pain is felt at an area where the viscus was once situated in embryonic life.
egs. #1. Diaphragmatic pain is felt at shoulder region (diaphragm was situated at the root of the neck)
#2. Testicular pain is felt at abdomen (testes descended from abdomen)
#3. Renal pain is felt in loin (kidney ascended up)
etc.
--
Have clinicians ever come across a case where the 'antiquated' embryonic viscus referred pain hypothesis was proven wrong? Convergence and subliminal fringe theories obviously make a lot more sense.
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Background: I treat pudendal neuropathy and the patients often have additional peripheral neuropathic pain generators. Patients have central sensitization. The sympathetic innervation of abdominal and pelvic viscera is referred to the thoracolumbar junction region of the spinal cord. Viscera lack somatic sensory innervation.
Thus patient with pudendal neuropathy may have colitis symptoms, irritable bladder, persistent genital arousal, etc.
Moreover, pressure on thoracic or abdominal cutaneous nerves at the rectus border can refer pains to viscera. Left T-8 caused a "tube of pain" to the vagina. T-10 caused urge to void. T-12 caused pain in the cervix.
These are but a few examples. The "pinch roll" maneuver of Maigne (TLJ syndrome) can cause pains in any viscera in various patients.
I would consider the sympathetic innervation, developing in the fetus, drives the focus of the visceral pain to the cord level of somites that produce the viscus.
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Is it inflammatory pain or normal pain
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the inflammation of the hemorrhoidal plexus can be supported by an altered intestinal microbiota with a loss of lactobacilli and bifidobacteria that lead to butyric acid production. .the absence of butyrate leads to an alteration of the tissue control system (PPAR alpha and Gamma able to block NfKB transcription) resulting in an inflammatory status that cause sensitization of afferent fibers due to prostaglandins. acidic pH also causes afferent fibers sensitization but makes available opioid receptors normally inactive, capable of responding to opiate drugs.
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Looking for research on short and longterm effects of trigeminal neuralgia on patients. All aspects of condition, treatment, physical course and outcome, emotional and psychological course and outcomes are of interest.
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Thank you - I agree with your statement about RG. Knowing, though, what is being researched leads me to information I can take to my doctor for discussion regarding my person case.
At the same time, I am also researching chronic pain conditions and their relation to what's considered a mind/body split, and how a doctor's relationship with their patient might contribute to, or help to heal, a mind/body split. Are you familiar with any research and articles related to these subjects? 
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Can someone help me with back pain questionnaire?
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you can use oswestry disability index and nordic musculoskeletel questionnaire 
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About 30% of Ethiopians are CYP2D6 ultra-rapid metabolizers. The Ethiopian Food, Medicine and Health Care Administration and Control Authority (FMHACA) said it has banned the drug codeine which is used for pain relief, in November 2015. However,codeine is still used in children and adults in this country. The ban and again,the resumption are not based on scientific evidence. To my opinion,codeine could still be a problem on such phenotype group and evidence on the safety should be deeply investigated. 
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Safety related to the use of codeine has been widely investigated both in Canada and United States. That is why I would not recommend using it especially with the North African population because of the high % of this population being ultra-metabolizers as you stated.
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I would deeply appreciate if any scientific evidence could support this .
I' ve found some articles describing how Reiki was beneficial animically as patients expressed wellbeing and could manage pain better.  However, as far as I'm concerced there is no such evidence as to conclude that reiki has truly benefits or it is just a placebo.
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 Thank you very much Mr.Laslett
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Dear sir, 
   Can you recommend website for read about pain 
Thank you 
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Dear Senthilkumar. You can reach the web:  www.iasp-pain.org, from the International Association for the Study of Pain, the most reliable, actualized and with a huge of evidence supported reports about several models  incluiding the biopsychosocial pain model.
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I wonder the exercise range (begin to stop), the angular speed of such isokinetic exercise for low back pain patients. Anyone have used this kind of exercise???
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Jin, I would read some of Stuart McGill's work.  His website is www.backfitpro.com and he is a professor at the University of Waterloo.  He does not recommend strengthening the spine through a range of motion with a load whether isokinetic of isotonic.  If the isokinectic exercise is done in a sitting position it places high load on the spine and if putting the spine through a range of motion (from flexion to neutral) reproduces the mechanism for herniating a disc (if done repeatedly).
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HOW TO CONTROL PAIN IN A FEMALE PATIENT 27 years old with multiple fracture ribs, small free fluid in the abdomen, fracture tibia, femur and pelvis?
She has also brain cotusion with GCS 13
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Multimodal therapy is  recognized as a critical pain management approach, especially when combined with early nutrition and ambulation, designed to improve functional recovery and decrease chronic pain conditions. Multimodal therapy included a wide range of procedures and medications, including regional analgesia with continuous epidural or peripheral nerve block infusions,  opioids, acetaminophen, anti-inflammatory agents, anticonvulsants, ketamine, clonidine, mexiletine, antidepressants, and anxiolytics as options to treat or modulate pain at various sites of action
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This 6 mo old girl is extremely painful, despite a morphine and amitriptyline treatment. She has an ANTRX2 mutation.
We tried oral corticosteroids without visible effect. 
Does anyone have experience of oral penicillamine in this indication at this youg age ? Other medication ?
Thanks in advance for this little girl and her family.
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Thank you Jean Pierre, but I'm not looking for homeopathy...
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Any EBP on acute pain teams? Who should be on the pain team besides (Anesthesiologist, CRNA, RN, Pharmacist, PT, Nurse Educator)? I am looking to implement a pain team in a small orthopedic hospital.
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I concur with the collective wisdom of learned colleagues, Dr. Kaell and Dr. Schiltenwolf  who underscore the very crux of the issue. They highlight the key reason I mentioned that interdisciplinary teams must consist of committed and dedicated individuals pulling together for the same goals rooted in the Hippocratic Oath (and the essential Princilpes of Ethics). At heart I trust that this is so when the best of us come together as committed human beings, scientists, and doctors who want to fulfil their central credo of healing, especially in multidisciplinary teams and also in our daily roles as doctors and healers, in hospitals or out in the community and / or facing special challenges.
However, for the reasons I mentioned earlier, our ability to deliver truly effective pain management is in danger and at the mercy of the various review boards, other structures, and shifting societal mores that seem to be around us over the past few years. Why? Because our care delivery, our goals of care, in fact our very credo, cannot be fulfilled in a vacuum.
Like it or not we are affected by forces and the shifting sands of opinions around us. I concur with Drs. Kaell and Schiltenwolf that the buy in of team members s essential to work in synergy towards effective outcomes. Yet, I think we must pause to remind ourselves that the central message, these central messages, we all have articulated on this page and in our practices, are in danger of obfuscation when so many ancillary individuals and structures carry the power to alter goals and messages. It is solely upto us as physicians and healers to keep raising the awareness regarding the rightful place of pain as the VITAL 5th vital sign that we must manage effectively with all the real / truly effective strategies at our disposal. Not only is this an important message to articulate and re-articulate by those of us "who have a voice on behalf of those who do not", it is also an important message with which to re-enthuse ourselves, our colleagues, and our mentees and students in order to achieve a true and collective faith in health CARE that our patients, especially those in intractable pain need, want, and yes, should receive.
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iv dexamethasone has been shown to decrease pain after laproscopic surgery.Can any other drug by intraperitoneal route be sufficient?
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Ketamina at the right dosage may be sufficient, especially in some situation, when more useful drugs are not available
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C5AR has been shown not to just be connected with inflammatory reactions, but seems to have direct actions on some brain area involved in pain perception.
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Sorry Giustino but I can't answer the question ... I'm only an economist. However, I have a request for you and your colleagues on the status of modeled claims. I have just drafted a paper on economic evaluation articles published in Value in Health. I would appreciate any comments (and possible venues where these questions could be raised). With best wishes. Paul Langley
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There may be altered joint arthrokinematics and other mechanical issue of an adjacent structure, which may contribute to lateral knee pain. So, what will be the best physiotherapy management?
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Hi Peter,
Very informative..... Thanks a lot.
Warm regards,
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I mean, I know it depends also on the location and the type of pain (headache disorder, neuropathic pain, musculoskeletal pain).
I'm looking a basic solution (2 channel) with software to start using it both for research and clinical use.
One channel could be use for eeg and the other? (e.g. muscle tone, skin conductance/impedence, blood pressure, breathing, heart rate variability).
Any suggestion?
Sorry if that is a little bit broad question
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Hi,
absolutely right, depends on the kind of pain.
puls volume sensor at the temple for certain types of headache works for most patients.
a huge part of the patients who can be treated with biofeedback have chronic musculosceletal pain. EMG for tension related muscle pain, usually upper (trapezius) and lower (erector spinae) back as well as neck pain. another group of patients that might profit from biofeedback along with physiotherapy are pain patients with tension related pain or pain due to asymmetrical posture or gait after injury. Not sure how your machine is set up, but for EMG which is very effective, you might need 2 channels.
other measures:
most patients in a psychotherapeutical setting tense up because of psychological stressors. that is often accompanied by an increase in heart rate. that might be another variable to control that is not directly linked to the direct physiological cause of the pain. so by teaching subjects/patients to control their reaction to stress it might help them to alleviate pain.
hope that helps a little
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I saw a 60 years odl women with an history of central stroke (left hemiplegia wich completely recover) and 3 months later complained of a pain in the left upper limb. Physical examination shows many painfull muscle Trigger Points (trapezius, infraspinatus, pectoralis major)
Can we make the link between the stroke and the mTrP: are they neuropathic?
Thank you and have a nice day
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I attach the refferences of some papers that expain the response to your question:
-Salom-Moreno J, Sánchez-Mila Z, Ortega-Santiago R, Palacios-Ceña M,
Truyol-Domínguez S, Fernández-de-las-Peñas C. Changes in spasticity, widespread
pressure pain sensitivity, and baropodometry after the application of dry
needling in patients who have had a stroke: a randomized controlled trial. J
Manipulative Physiol Ther. 2014 Oct;37(8):569-79.
-Chen ZM, Wu XT. [Clinical efficacy observation on primary trigeminal neuralgia
treated with joint needling method at the trigger point]. Zhongguo Zhen Jiu. 2012
Jun;32(6):499-502.
-Zeilig G, Rivel M, Weingarden H, Gaidoukov E, Defrin R. Hemiplegic shoulder
pain: evidence of a neuropathic origin. Pain. 2013 Feb;154(2):263-71.
As central as peripheral sensitization is presented in shoulder pain in relationship with myofascial trigger points.
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In our pain center we use a five days subcutaneous protocol with 100mg/24 hours.
it sometimes gives good results but also sometimes the situation remains unchanged.
Your opinion interests me, thanks.
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Firstly ketamine does not work in the patient who is tissue magnesium depleted.   Therefore oral 1 week or IV 24 hours loading with Magnesium is required first.
 Best results are combining with Clonidine which usefully also blocks the ketamine induced tachycardia and hypertension.
Generally higher doses produce better results ie 40mg/hour but one has to titrate up slowly to have patients tolerate that.
Even so I find only 1/4 patients benefit from this advanced protocol treatment
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There are more then few people who suffer continuous pain about a part of the body that exist or is missing when the injury is not there any more. This is called Complex Regional Pain Syndrome, CRPS. By researching it lately it might have been caused by the lack of swomething at the point of the injury. The body keeps radiating the pain as if the injury still there. Does someone have an experience with such pains and the cause for it or the lack of something that have caused it. This might help a lot by trying to eliminate the pain using new methods of healing for a young girl who suffers from it.
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In my experience in CRPS the psychological patient´s background  is crucial. The central mechanisms linked to the immunological and sympathetic nervous system might play a role. It´s necesary, specially  in a a young girl, to explore the personality traits and work in accordance to. Very important: reassure the patient. It´s the power of mind.!
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I need to perform von Frey test on mice. I am going to use Chaplan's up-and-down method. But how long do I need to wait until I would be able to perform another trial, for example 24 hours later? Or the necessary interval between trials?
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I reckon that would depend on how long your experiment would be. If you need to measure only three time points after a treatment it would be ok to test them twice (morning and evening) on the first day and then 24 hrs later. However, if you are planning a longer experiment I would not recommend a daily testing schedule. Repeated testing (considering the long acclimatization time and testing time in mice) will cause stress and thus weight loss over time, which of course would be an animal welfare concern.
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Patients have several pain scores before and after medication treatment. Would like to apply a longitudinal or time series model to compare slopes before and after and evaluate the medication effect on pain reduction.  
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Hello David! I have another suggestion: the pain trajectory. This simple approach describes the pain of your patients with a regression line. 
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I'm not sure whether it is justified to perform some type of normalization on the patient´s pain scale data, spliting 1-10, the smallest intensity to biggest intensity..  This is a comparison of the two groups (control a treated) before and after treatment. Researchers maybe poorly informed the patients about the rating scales so some patient´s evaluate pain with maximum values in comparison with others, despite the fact it is not a serious health problems characterised by maximum pain.
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I think this is one of the cases where the proverb fits: "shit in - shit out".
If the patients are not well informed and may differ in their understanding and attitude towards the scale, if the data obtained from is not comparable.
As long as you have no detailed information about all the paitents' understanding and motivation (e.g. what other patients served as "reference", and how precisely did they serve as reference, how did the patient "adjust" his choice etc) there won't be any sensible way to correct or normalize your data.
There is at least one very important thing one can learn from this experiment:
The quality of the data is fundamental for all further analysis. This quality depends much on the study design and the protocol (methods). Analysing/interpreting data without being sure that the data is really ok is a waste of time.
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Im am doing my CTR now , and the topic is renal colic, how safe is our approach in UK, and how safe is the use of NSAID's in a pt with a potential post-renal obstructive renal injury. Thanks
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I would suggest this systematic review by Cochrane Database Syst Rev
Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic. Cochrane Database Syst Rev. 2005(2):CD004137.
Briefly
A Cochrane review concluded that both NSAIDs and opioids provide effective relief from renal colic. Some evidence suggested that NSAIDs were more effective, and that opioid use was associated with more adverse effects, mainly vomiting. Trials included in this Cochrane review did not directly assess gastrointestinal bleeding or worsening of renal function. However, these potential adverse effects were infrequent in the Cochrane review and in a previously published meta-analysis of NSAIDs for renal colic ( Labrecque M, Dostaler LP, Rousselle R, Nguyen T, Poirier S. Efficacy of nonsteroidal anti-inflammatory drugs in the treatment of acute renal colic: a meta-analysis. Arch Intern Med. 1994;154(12):1381–1387).
Treatment harms are important, and trials designed to show if NSAIDs pose a risk in kidney stone treatment would be helpful. However, based on a paucity of evidence that NSAIDs are harmful in most patients with kidney stones, physicians should not exclude NSAIDs as an option for relieving renal colic.
These following comments were from "Am Fam Physician. 2012 Jun 15;85(12):1127. by CHARLES CARTER, MD, FAAFP"
Best regards,
Wisit
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It is well known that pain plays an important role in the early period of life, as it informs an individual about the danger for his health (role of protection and education). Thus, people with rare form of neuropathy, that cannot experience this sensation, are used to having a lot of traumas and other health damage even as adults. It is reasonable to suggest that a problem can come up when painkillers are taken against the pain caused by people’s bad habits (ex. excessive workload - headache, bad nutrition habits - stomachache). The long-term analgesics intake after each occurrence of pain can lead to their unawareness of the consequences of such behavior. As a result, the educational function of pain is highly perturbed. This can explain the lack of instinct of self-preservation in individuals, who voluntarily damage their health (ex. smoking).
Is there any research that has already been made on this subject? What path should I take to find more information about it? Thank you
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Absolutely from several vantage points do opiate pain killers taken outside an acute condition setting prevent true healing, introduce new challenges to well-being, and represent egregious health practice. It is the cause of so much suffering in the US that deaths from their use represent a greater threat than do automobile deaths on the highway. I am attaching one of my consumer monographs on the topic here. 
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I am looking for a validated tool that can identify muscle pain or myalgias as major predominat factor in chronic pain patients? Are there any such questionairres used in fibromyalgia research for example? 
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currently there is no validated questionnaire that can distinguish muscles over other sources of pain.  Physical exam still remains the most relabel way of establishing myalgia or fibromyalgia.
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I am trying to find out level of cartilage destroying enzymes which is associated with crepitus sound with pain.
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Crepitation suggests sever chondromalacia (gr II and III). I have no experience with the measuring the level of destroying enzymes.
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I see many anesthesia techniques can be used for kidney transplantation.
In my hospital for recipient we use lower combined epidural & intravenous anesthesia (TCI propofol). Postoperative analgesia achieved by continous ropivacaine 0.15% + fentanyl 2 mcg/mL, rate 8 mL/hr via epidural catheter for 3 days and iv paracetamol.
For laparoscopic living donor we use combined epidural & general anesthesia (volatile). Postoperative analgesia: intermittent epidural bolus (bupivacaine 0.125%, morphine 2 mg, volume 10 mL, 2x/day) + iv paracetamol.
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For renal transplant recipients, we use Epidural Anesthesia and use fentanil with ropivacaine 0,2% In PCA post operatively. For donor, we use thoracic epidural in conjuction with GA.
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normally we use ibuprofen and paracetamol combination or ketorol or aceclofenac. but there is difference in responce in different patients. 
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PAIN RELIEF FOR POSTOPERATIVE PATIENTS
The most effective single dose oral analgesics for acute postoperative pain in adults have been identified by Oxford researchers in a Cochrane review of 45,000 participants across 350 studies.
Over 70% of participants with moderate or severe acute pain who took a single-dose achieved good pain relief with 120mg etoricoxib (Arcoxia) or the combination of 500mg paracetamol plus 200mg ibuprofen.
With other drugs, such as 1,000mg aspirin and 600mg paracetamol taken on their own, only 35% benefitted.
The worst was codeine, with only 14% getting significant pain relief. The period over which pain was relieved also varied, from about two hours to about 20 hours.
So everyone is different and you will find what works for you. It may be different to that which works for your friends.
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I plan to do a questionnaire survey to find out the prevalence of back pain among computer users. Because I have limited time, I am looking for an already constructed questionnaire. 
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I think you can modify the nordic questionnaire according to the requirement of your study. Further you can prefer the OSHA’s MSD questionnaire or multi-method ergonomics checklist for your use.
Cohen AL, Gjessing CC, Fine LJ, Bernard BP, McGlothlin JD. 1997. Elements of Ergonomics Program- A primer based on workplace evaluation of musculo-skeletal disorders. DHHS (NIOSH) Publ No. 97-117
Nag P. Work systems-checklists. In: ILO Encyclopedia of Occupational Health and Safety. 4th ed. 2914–2924 (Chapter 29). Geneva International Labour Organization; 1998
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I want to know when, based on HIT-6 scores, a patient is clinically improving, e.g. pre- or post-treatment. I'm looking for specific data for tension-type (episodic) and cervicogenic headaches.
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We want to know if there is some kind of cut-off score that correlates with a minimal clinical improvement/deterioration. For instance a patient scores 74/78 on intake, during the intervention he scored a 62/78. How can this be interpreted? Can one say that he actually has a 'better' quality of life? 
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In European countries, outside the UK, many patients with refractory angina pain are referred to the implantation of spinal cord stimulator. We do this in our center as well. The studies have shown this method is effective in decrease of pain intensity and improvement if the quality of life (Lanza et al., Neuromodulation 2012; Borjesson, Future Cardiol 2011). But from our experience, these patients may get complicated - electrode displacement, infection, etc. We have had quite good experience within last few years with a following algorithm - 1. US guided stellate ganglion block - if the patients respond - 2. VATS thoracic sympathectomy- Any comments, ideas, experiences?
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I concur with Johannes - the other problem with SCS is that the person is, from that time onwards, a patient of your service. Developing effective coping strategies, understanding that this pain is not an indication of harm, and judicious use of blocks/sympathectomy is far less prone to complications.
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Due to continued pressures related to prescription drug abuse, the DEA and local state organizations (Boards of Pharmacy, Boards of Medicine) are considering the reclassification of Hydrocodone (and combination products such as Vicodin, Norco, etc) as a Schedule 2 medication.
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Hi Michelle. The move of hydrocodone to Schedule II isn't just being considered, it is going to happen effective October 6, 2014. (DEA Final Rule published August 22, 2014 - http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-19922.pdf ). And Tramadol was made a Schedule IV drug by DEA effective August 18, 2014 (http://www.gpo.gov/fdsys/pkg/FR-2014-07-02/pdf/2014-15548.pdf ). For prescribers with Schedule II privileges, I would guess that not much will change, but I agree with Barry that codeine may well make a comeback.
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I would like to start some research on whether primary care opioid prescribing for chronic non-cancer pain meets current guidelines, especially for patient safety. There are too many recommendations in our guidelines to use all of them, some are more/less important, and some are difficult to operationalize for a chart review or ongoing quality improvement.  I have seen some initial work on quality/safety indicators for opioid prescribing by others in unpublished and grey literature.  Does anyone know which would be the best to use, and where/how this is being measured?
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In terms of identifying indicators to help determine more safe versus less safe opioid prescribing practices for quality improvement (and potential research), I recommend to look at frequency of certain physician behaviors that can be verified through more than one source during chart review.  Frequency of office visits, frequency of urine drug testing (that takes into account the frequency of office visits), frequency of prescription refill requests without an office visit, documentation of use of risk assessment tools (such as the ORT mentioned by Vahid Mohabbati), use of a pain medication agreement, documentation of at least one discrete and specific pain diagnosis, and co-prescription of riskier medications such as benzodiazepines (as mentioned by Yacov Fogelman).  These can be identified in the chart and verified by cross-referencing with lab results, pharmacy records, charges billed, etc. For some general examples of how this has been done, you may want to see the following articles:
Yanni LM, Weaver MF, Johnson BA, et al: Management of chronic nonmalignant pain: A needs assessment in an Internal Medicine Resident Continuity Clinic. J Opioid Manage 2008;4:201-211.
Chelminski PR, Ives TJ, Felix KM, et al: A primary care, multi-disciplinary disease management program for opioid treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity. BMC Health Serv Res. 2005;5:3.
Adams NJ, Plane MB, Fleming MF, et al: Opioids and the treatment of chronic pain in a primary care sample. J Pain Symptom Manage. 2001;22:791-796.
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I am interested in compiling evidence on various non-surgical approaches for EDS patients including; active rehabilitation, orthoses, and manual therapies, focusing more specifically on the musculoskeletal manifestations. As the literature is sparse, I was wondering if anyone has input, or know of any specialists I can try contacting. Also, if there are any trials currently being conducted or similar work being done kindly bring them to my attention! Thank you!
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You might like to look at this recent systematic review paper
Physiotherapy 100 (2014) 220–227
Systematic review;The effectiveness of therapeutic exercise for joint hypermobilitysyndrome: Palmer et al
Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.physio.2013.09.002
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I'm thinking specifically about back pain but any article on the topic would be great.
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Dear Fred
This article may be useful for you
J Vasc Interv Radiol. 2014 May;25(5):725-33.
Pelvic congestion syndrome: etiology of pain, diagnosis, and clinical management.
Phillips D1, Deipolyi AR2, Hesketh RL3, Midia M4, Oklu R
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Surgery would be suggested to a 61 years old women patient, but she is not accepted. The patient does not feel neurologic cladication.
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The scientific society knows, dear Gabor, that there totally no evidence for your ideas. Sorry!
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I want to use OHIP for OFP patients. Any experience out there?
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We are (University of Talca, Chile) using a TMD Ohip- related quality of Life developed by J, DURHAM from newcastle University. 20 original question from OHIP-49 and 2 new Questions tested with a high Cronbach alpha. Journal of Oral Rehabilitation 2011 38; 871–883. Thanks for share.
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I found a combination of newer generation intravenous NSAIDS (dynastat) and oral opioids (Tramadol) works for many patients, but not all. Can you share your experiences?
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Pain post tonsillectomy particularly reaches a peak in most cases at day 6 post surgery. NSAIDs are the most effective analgesics. Pain control is optimised by education (make patient aware pain and earache worsens rather than improves up to day six), use of the jaw (chewing gum is a useful ajunct, patients need to be educated to avoid living on a soft diet) and possibly steroids.
Opiates are less effective in the days following surgery
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Is it correct that it manifests it's effects within 2-5 minutes as mentioned in this article which I am unable to access and later cited by a recent text on opioids.
Lewis, J. W. "Structure-Activity Relationships of Opioids− A Current Perspective." Proceedings of the VIIIth International Symposium on Medicinal Chemistry I. Stockholm, Sweden: Swedish Pharmaceutical Press, 1985.
What do clinicians feel about this?
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How did you measure the onset of effect Lucie. Did you do an EEG look at the Bispectral index?
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I've just read two recent papers that have me musing: LAKEMEIER S, Lind M, Schultz W, Fuchs-Winkelmann S, et al. (2013) paper looks at a comparison between steroid injections and radiofrequency denervations for people with low back pain. The conclusion suggests that both procedures "...appear to be a managing option for chronic function-limiting low back pain of facet origin with favorable short- and midterm results..."; and ANDREW MOORE R. (2013) "What Works for Whom" suggesting that statistical significance is less useful than a patient-centric view of effectiveness.
My question is - if chronic back pain is a condition likely to persist, what are the effects in terms of beliefs about pain, quality of life, interference in "living well despite pain" when a person needs to keep attending clinics to have invasive treatments?
I say this after seeing people who have attended self management programmes, with the same pre-treatment pain intensity, distress, disability as those reported in Lakemeier's paper, remain well with reduced distress and disability - and more importantly from a systems perspective - less need to rely on healthcare.
How can this be measured? Has anyone carried out a head-to-head economic study of self management vs ongoing procedures? Or am I simply showing my self-management bias?
The two references:
LAKEMEIER S, Lind M, Schultz W, Fuchs-Winkelmann S, et al.
A Comparison of Intraarticular Lumbar Facet Joint Steroid Injections and Lumbar
Facet Joint Radiofrequency Denervation in the Treatment of Low Back Pain: A
Randomized, Controlled, Double-Blind Trial.
Anesth Analg. 2013.
ANDREW MOORE R.
What works for whom? Determining the efficacy and harm of treatments for pain.
Pain. 2013 Mar 15. pii: S0304-3959(13)00119-X. doi: 10.1016/j.pain.2013.
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This is a difficult question to answer. As I'm sure you know, most economic models for the management of any chronic illness vary considerably in depth and breadth and I have personally struggled quite a bit to incorporate models of direct and indirect cost into my own chronic pain research. I'm aware of a few manuscripts that describe the general cost of chronic pain management programs (see Gatchel & Okifuji, 2006 for an example), but I am unaware of any prospective comparative trials with a strong economic endpoint. Most seem to agree that information about healthcare utilization patterns before and after an intervention can serve as a reasonable surrogate for more refined cost models, but I have yet to see any studies advance this line of research beyond basic measures of disability and absenteeism (missed work time). I personally believe that studies of work presenteeism (present at work, but less productive) are sorely needed. For a few of my manuscripts I have actually counted the # of appointments attended in general and specialty clinics to represent healthcare utilization, but this method is only as reliable as the medical records reviewed for the count. This count revealed a significant decrease in healthcare utilization after self-management intervention (but I did not compare head-to-head with other interventions). It may also be good enough to ask patients to recall the number of visits for care to study utilization, though I don't know how reliable these data would be compared to medical record review. I suspect that more detailed cost estimates would support your suspicion that self-management offers significant long-term cost benefits.
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I would like to investigate the relationship between pain and Naadi (a significant parameter used to diagnose diseases in Indian medicinal procedures in Sidha, Ayurvedha and Naturopathy). Does anyone have any information on it?
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Certainly few scientists are working on this principle and they have got some success also .Main issues are of Reproducibility and reliability.
Pls check the published works of Dr.Anirudha Joshi as well as Mr. Bharat S. Shete on Pulse diagnosis.
As per principles of Ayurveda Vata Nadi should be predominant in conditions of pain.You may get some relation between intensity of pain and pressure in Vatnadi.Understanding Nadi actually comes by experience and its not just pressure in Nadi which is felt but its movement,Rythm and relation to other nadis .Hence i will advice to first understand the entire concept of how Nadi is examined .Ideally involve some Nadi expert in your work.Look at concept of reading Nadi in its totality.Isolated approach towards Nadi may may be incomplete and can lead to failure.
Its really good work,But difficult to accomplish.
If possible contact SVYASA university in Bangalore .They are also working on this concept.
Wish you success in your Work
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Many clinical trials have demonstrated the effectiveness of gabapentin and pregabalin administration in the perioperative period as an adjunct to reduce acute postoperative pain. However, very few clinical trials have examined the use of gabapentin and pregabalin for the prevention of chronic postsurgical pain (CPSP).
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Gabapentin affects voltage-dependent calcium channel subunit alpha-2/delta-1 (CACNA2D1). If this channel were associated with acute pain mechanisms (peripheral or central), one would think the drug to be useful in pre-op or post-op regimens. However, there is no evidence to suggest this action. Subsequently, there is really no scientific rationale to administer the drug peri-operatively. Alternatively, with some injury/trauma/surgery, CACNA2D1 is known to upregulate in the nervous system and it is this change that facilitates the beneficial actions of the drug.
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In the 1980's my colleagues and I found an association between parafunctional oral habits and a diagnosis of common migraines. The last clinical paper I wrote on the subject is attached. I am considering initiating additional research in this regard, but wanted to first find out if this had been investigated further by others. I have found more recent studies on oral habits related to facial pain, but not directly related to those diagnosed with common migraine.
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I just looked over the article. I was vaguely familiar with this approach back in the 1980's when I was involved in reviewing the literature. It appears you and others are making progress in improving the efficiency. In relation to my own interests, have you or others looked specifically at a uniform common migraine group versus classic migraines in your treatment since I suspect these represent two distinct populations. Additonally, have you done this directly with the temporalis muscle on the affected side or have you used other sites? What kind of long term effects do you get or does this mainly provide immediate symptomatic relief only? I think two interesting aspects. One would be to look at common migraine patients versus classic migraine versus no pain controls and to have the patients clench their teeth for several minutes (maximum of 5 probably) or until the pain was judged unbearable. With no pain controls this is known to create pain that resolves fairly quickly. The question would be whether this leads to the characteristic headache pain in the common migraine versus the classic migraine patients. If so, a second study could be whether the treatment you discussed would differentially affect common versus classic migraine patients. Additionally, if the common migraine patients were to develop pain following clenching, could your technique alleviate the pain? Just some initial thoughts. I am unsure as to whether any of these studies may have already been done. Bob
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Least invasive pain route is well established in palliative medicine but IM injections are still common in acute managment. Specifically, I need to make a valid case to change practice of IM injections for immediate post-operative patients.
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As Mr. Enrique has suggested, severety of post operative pain can vary with the type of surgery (caesarean to open chest surgery, amputation or tumour removal. The mechanism of pain varies, the mode should vary and as Mr Borja suggested, multimodal and rotatory schedule with multiple agents suits peri and immediate post op. pain management (to manage inflammation, release of endotheins by tumour cells leading to pain, neuropathic pain etc.). As you suggested, the least invasive mode is intramuscular or oral, which works well with caesarean patients, and good old practice of acupuncture. This case needs a meta analysis on the use of oral or intramuscular route.
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Of all the ankle ligaments present, the most commonly (85 %) involved ligament to be sprained is the Lateral ligament complex (Anterior Talofibular, Posterior Talofibular and Calcaneofibular Ligs.). Based on the severity (stable / unstable) of sprain the protocols are carried out usually. I came across this article and found it quite new that these UNSTABLE ankle sprains can be corrected without SURGERY (based on evidence obtained from more than 1500 articles on the Rx for ankle sprain). So, could the unstable ankle sprains be rehabilitated in a FUNCTIONAL protocol (as this article has proven) ??
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The surgical when compared with conservative treatment shows no difference in the results particularly in ROM and stability.(my personal experience)
Functional treatment with a short period of protection and early weight-bearing, followed by physiotherapy is my option in the majority of the patients. I think the surgical treatment may be superior in selected cases , for example, in a person who is skilled in competitive track and field events (athletics)
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I have applied local mini-injections of heparin surrounding deep muscle and deep cutaneous lesions with excellent results. No scarring is observed, only regeneration of the original tissues. Can this be transferred to aleviated diabetic neuropathic ischemia in early stages?
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For the treatment of diabetic neuropathy we use intraosseous blockade with excellent results. www.pain-clinic.ru
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Work comp in my area is making some changes to their requirements. One of which is they want providers to monitor pain and function if prescribing opioids. They made a suggestion of a tool to use but I thought I'd ask the community.
Does anyone have a favorite tool to measure and track pain and function? Ideally it would be a simple (for both patient and provider) and cheap tool that I can use that is not diagnosis specific.
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For simple performance tasks - timed repeated (x5) sit-to-stand and gait (50 foot speed walk (from which gait speed can be calculated and six minute distance test for an endurant component (Simmonds et al, Spine, 1998). We also use the BPI for pain. We have just done a study with Veterans in chronic pain and on opioids - using these outcomes. Note that self reports of function and measured function are complementary and you need both
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The social costs of cares for chronic pain patients is an important aspect, also giving problems to the health care systems. Any suggestion to increasing visibility, with not negative influences on the costs for the national welfare system would be more than welcome.
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Maybe with studies that show the burden of pain in our society, and this burden assesses with the morbidity, disability, emotional consequences and lose of quality of life.
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Nociception is known to cause pain in a wide range of situations. However, nociception itself is not sufficient nor necessary for a person to feel pain according to several researchers.
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@Bronnie
We are not in disagreement at all I think. I have never disputed, nor am I reluctant to integrate the psychosocial with the biological aspects of pain when discussing the theoretical aspects of pain. It is just that you and I probably see, in the main, the opposite ends of the spectrum While most of my patients have a "bio" component that predominates in terms of treatment needs and the psychosocial is along for the ride, I suspect you see the other end where the "bio" is so buried in the psychosocial dimension that the bio seems incapable of being teased out from the complexity of the florid chronic pain patient. I do see these patients too but less frequently. Even the most obvious 'bio' case - like a fracture or a wound carries with it the learned experiences and responses to past instances of pain woven into a behaviour pattern. This is why one patient with bones sticking out of the leg will grit his teeth and make humorous comments to the ambulance officers about how he will have to put off the Tongariro traverse until next month, while another will scream and cry, wail and moan as if he will be crippled and in pain forever. The injury is the same but the responses are different. The treatment - at least initially is not that different though - provide relief from nociceptive input, reduce the fracture, stabilize it and let nature do the physical healing. However, the different responses are cues to how pain relief and rehab should proceed. They are cues only however. I have seen the former patient become disabled and chronically painful because of poor management and interaction with the health care system despite the initial rather positive response type. Conversely I have seen the latter case calm down rapidly once pain is under control and proceed through rehab without a hitch despite the initial 'yellow flag' type of behavour initially.
My point here is that the clinician must be responsive to what is needed when it is needed, and not doctrinaire in either direction about what approach or mixtures of approach are needed, for it can and does change from patient to patient, and for any given patient throughout the process of acute presentation to rehabilitation.
Again, I reiterate, I have no quibble with your statement "..that psychological and social factors are present in all experiences of pain." Absolutely correct - we are not insects but perceptual / cognitive / emotional entities, enormously complex and individually unique. Nociception is a primitive sensory level data input and pain is the experience of, and the behaviour in response to, that sensory input. I think pain arising completely de novo is rather rare is it not?
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Can sleep 'dampen' chronic pain, and if so, how?
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And from a more informal perspective based on my clinical experience, people who have slept well have more energy and resilience to cope with stressors in general during the day. Pain is a stressor, so good sleep probably helps.
These are a couple of good papers:
1.
When is pain related to emotional distress and daily functioning in fibromyalgia syndrome? The mediating roles of self-efficacy and sleep quality.
Miro, Elena; Martinez, Maria Pilar; Sanchez, Ana Isabel; Prados, German; Medina, Ana.
British Journal of Health Psychology. Vol.16(4), Nov 2011, pp. 799-814.
2.
The association between chronic low back pain and sleep: A systematic review.
Kelly, Grainne A; Blake, Catherine; Power, Camillus K; O'Keeffe, Declan; Fullen, Brona M.
The Clinical Journal of Pain. Vol.27(2), Feb 2011, pp. 169-181.
3.
Intraindividual variability in daily sleep and pain ratings among chronic pain patients: Bidirectional association and the role of negative mood.
O'Brien, Erin M; Waxenberg, Lori B; Atchison, James W; Gremillion, Henry A; Staud, Roland M; McCrae, Christina S; Robinson, Michael E.
The Clinical Journal of Pain. Vol.27(5), Jun 2011, pp. 425-433.
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I have been using these injections in my selective patients with good outcome; I would like to know your thoughts on this
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I usually recommend just 1 time injection, and I check again within a week. If pain decreased more than 50% and their motor function is not worsed, I prescribed oral medications for PRN usage. If not, especially worsening motor fuction, I recomment decompression, endoscopically or microscopically. Response of 1 st injection is the key to differenciate ....
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I have a male 60 year old patient who has Psoriatic Arthritis well controlled with 12.5mg of metholtrexate per week. Because of previous crisis' he has a knee replacement, gets painful feet, has o/a elbow and various other bits and bobs. Has a job where he is on feet all day, 8-10 hours.
He does feel he has to supplement with analgesics to get through his day as he has 6 children to support and is self employed....so if he doesn't work he doesn't get paid
On a daily basis he takes an ibuprfene 400mg and a pill containing 500mg of paracetamol and 20mg of codeine 3 times per day for the past 4 years . He seems happy and is able to work productively......without apparent negative side effects. His liver enzymes are only slightly raised. He is not constipated and takes regular extra fiber toward this end. He likes an occasional glass of wine in the evening.
He walks regularly and twice a week has a swim and sauna at his club.
Considering the addictive nature of opioids like codeine should I encourage him to cut down or leave well enough alone as he SEEMS to be doing well?
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In Germany, the suggested maximum daily intake of Paracetamol is 4000mg per person. So even if he takes the 500mg 3 times a day he'd still be fine. For the liver, really more the acute intoxication (-> producing the toxic metabolites) is the thing to worry about not so much the ongoing intake; and as you're checking his liver enzymes already he should be absolutely fine.
Also there is a combination drug (Contraneural® Paracetamol/Codein) that has 500mg Paracetamol and 30mg of Codein. From the guidelines it says that you can take it up to 8 times a day. So also with the Codein he should be fine.
If he'd be addicted to the codein you should generally see either some craving, increase in dosage or abstinence phenomena. At least you didn't mention anything about an increase in dosage.
In general I think he's fine with that dosage of Codein and Paracetamol.
What I'd take care of is an Analgesic Nephropathy as he's using a combination of these drugs. So you might want to monitor his kidney function.
Best
Sebastian
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Is there any evidence for the use of multiple long acting opioid analgesics for the management of pain in the hospice/palliative care setting (e.g. MS Contin and fentanyl patches)?
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I too am curious how in 2012 you would not first check the Pt's CYP-450 and opioid response Hx and then decide what would be the most genomically indicated single opioid for the specific outcome decided upon with the Pt and the family. I too fail to see the benefit of 2 vs. 1 specific agent. On Linda's point about "pain control specialist physicians," and especially hospital physicians, if I want to increase the chances of my Pt's obtaining improved pain control, I tell them how to go about checking the prescribing physician's credentials in their putative pain medicine specialty. And, if it doesn't exist, I advise the Pt to "walk" (right out of the "pain doctor's" office). Pain control is best provided today in this period of scarce resources by reducing doctor-caused error, because of documentable competence in managing of opioids, espeically when complications develop.